How to Treat Hyperhidrosis: A Guide
We’ve put together an overview of the most common treatment options for hyperhidrosis. Our guide can help you get a well-rounded view of the treatments currently available to treat hyperhidrosis, how they work, and the pros and cons of each to help you make an informed decision as to what you think might be most suitable to your needs and lifestyle.
Hyperhidrosis is a medical condition characterized by excessive sweating. Those with hyperhidrosis have overactive sweat glands that produce 4-5 times more sweat than the average person, and in excess of what is needed for thermoregulation and without the appropriate stimuli (heat, exercise, etc.). No cure exists for hyperhidrosis, but treatment is widely available. Treatments for hyperhidrosis are aimed at neutralizing the connection between the nerves and sweat glands. It is thought that primary hyperhidrosis is the result of overactive signals being sent from the sympathetic nervous system to the sweat glands, making them produce a lot more sweat than is needed. Therefore, these treatments are generally aimed at creating a “plug” to block the sweat from coming out of the pores, neutralizing the connection between the nerves sending the signal to the sweat glands to reduce the amount of sweat being produced, or permanently eliminating the sweat glands.
Note: Check any contraindications before beginning a new treatment and to know if it's suitable for you. Speak to your doctor before starting any new treatments. Many of the options listed below require a prescription or consultation with a licensed professional.
Treatment for Primary Hyperhidrosis
Antiperspirants vs. Deodorants
The first line of treatment for hyperhidrosis is antiperspirants. While many use the terms deodorants and antiperspirants interchangeably, they are not the same. Deodorants help prevent and conceal body odour, but do not have any “anti-sweat” properties. Antiperspirants, on the other hand, have properties (aluminum salts) that can temporarily halt the production of sweat.
Topical application of aluminum salts that are absorbed into the skin are seen as unfavourable by some, and have been studied in relation to their potential risk with certain cancers. These studies have proved inconclusive, and there is currently no direct link between the use of antiperspirant and cancer, however many choose to opt away from this as a precaution. Many opt for aluminum-free deodorants, however these will not stop you from sweating, as they are not antiperspirants. Antiperspirants must include aluminum in order to work, as this is the active ingredient that temporarily halts sweating. If you would rather not apply aluminum antiperspirants on your skin, then this is not the treatment option for you, and you may want to look into iontophoresis treatment for hyperhidrosis as the next step.
What is the active ingredient in antiperspirants?
Most antiperspirants are formulated for underarm application, though there are some antiperspirants formulated for the entire body, particularly the hands, feet, groin, and scalp regions. They come in different formulations such as gels, creams, sticks, powders, and wipes. The main active ingredient in antiperspirants is aluminum salts, generally in 12%-25% concentrations. The aluminums can take several names such as: aluminium chloride, aluminium chlorohydrate, aluminum sesquichlorohydrate, aluminium zirconium, etc. There are also “clinical strength” antiperspirants, which are sold over the counter and have a higher concentration of aluminum salts. Maximum strength antiperspirants are only available through prescription (Drysol, Qbrexza, etc.). Depending on the concentration of aluminum salts, as well as your level of activity, the anti-sweat properties can last from up to a few hours to a few days.
How do antiperspirants work?
Antiperspirants are applied directly to the skin (topical application). The purpose of the antiperspirant is to decrease the volume of sweating by creating “plugs” in the underarm (or region it is applied to). These plugs are made of aluminum salts, which dissolve into the skin with the help of perspiration. Essentially, the aluminum mixes with the sweat on your skin, dissolving the aluminum that is then absorbed into your pores, which creates “plugs”. These plugs are temporary (generally lasting up to 24 hours) and are washed away over time.
It is important to follow the directives of the antiperspirant, as most require application the night before on clean, shaven skin. Going against these directives (such as applying the day of, or on unwashed unshaven skin) may reduce effectiveness. Many antiperspirants are a 2-in-1 with deodorants, so they also leave a scent behind to mask any unwanted body odor.
Antiperspirants: Pros and Cons
- Widely available.
- Simple to use.
- Can cause skin irritation and high aluminum concentrations can cause discomfort and burns.
- Ineffective for moderate to severe sweating (those with hyperhidrosis).
- Recurring cost.
- Constant application.
Botulinum Toxin Injections
Botulinum Toxin Injections for Hyperhidrosis
Botulinum toxin (also commercially known as Botox) injections for hyperhidrosis are a common treatment option for the condition. It is a less common use of the substance that is known for its use in cosmetic procedures, such as to reduce the appearance of wrinkles. Currently, the FDA has only approved Botox for the treatment of primary axillary (underarm) hyperhidrosis, however many specialists will use it “off-label” to treat other areas of the body. It is not always recommended for hands as it can cause temporary pain and weakness in the hands, nor the feet as they are too sensitive. It is most effective for the underarm region, and is also commonly used to treat the forehead and scalp regions.
What is the active ingredient in Botox?
Botulinum toxin (Botox) is a drug made from a toxin produced by the bacterium Clostridium botulinum. It is a neurotoxin, which affects the structure or function of the nervous system. It's the same toxin that causes a life-threatening type of food poisoning called botulism. Doctors use it in small doses to treat health problems, such as hyperhidrosis.
How do injections for hyperhidrosis work?
Botulinum toxin injections alter the function of neurotransmitters, which are chemicals found in the body that are responsible for making the body react in certain ways (i.e. sweating when it’s hot). The injections block the nerves responsible for activating your sweat glands in the treatment area.
While it’s normal for your nervous system to activate your sweat glands to cool your body when your body temperature rises, for hyperhidrosis sufferers, this signal is essentially always active, and these injections weaken the response, essentially temporarily paralyzing the nerves, which controls the sweating in the injection area. When your nerves can’t signal your sweat glands to produce sweat, the sweating significantly decreases. This effect wears off after several months (generally 4-12 months, depending on what area you are treating) and then must be redone. Treatment sessions for one zone on the body (underarms) costs upwards of US $1,000 each. The cost varies based on which zone you are treating, but can generally range from hundreds to thousands of dollars.
This treatment is non-invasive but does require the use of needles and multiple (generally hundreds) of injections on the treatment site. The botulinum toxin is contained to the treatment zone, as it is shallowly injected into the skin. There are moderate side-effects associated with botulinum toxin injections, such as temporary bruising, bleeding, pain, redness, swelling, and infection at the injection site. Some more serious side-effects can also occur.
- High effectiveness.
- Can be done on multiple targeted areas of the body.
- Costly (>$1,000 per zone, per session, on average).
- Recurring treatment must be repeated every several months.
- Not suitable for people with fear of needles.
- Need to visit a doctor’s office.
Prescription oral medications are sometimes prescribed to treat hyperhidrosis. This is a systemic treatment, meaning it treats and affects the entire body at once. Targeted treatment is not possible with a systemic treatment.
What drugs are prescribed for excessive sweating?
The most commonly used medications for managing excessive sweating are anticholinergics. These include medicines such as glycopyrrolate, oxybutynin, benztropine, propantheline, among others. Anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that transfers signals between certain cells to affect how your body functions.
The work by blocking the chemical messenger acetylcholine as it attempts to travel to receptors on the sweat glands that are responsible for triggering sweating.
In addition to anticholinergics, some beta-blockers (such as propranolol) are prescribed to treat hyperhidrosis. These medications are also commonly used to treat anxiety, therefore these may be more useful if the patient suffers from excessive sweating triggered by stress and anxiety.
Anticholinergics as a treatment for hyperhidrosis
Because anticholinergic medications work systemically, they cannot target one area of the body, unlike other hyperhidrosis treatments. That means that they decrease sweating and moisture all over the body, even where sweating is not a problem. This can lead to side effects such as dry mouth, constipation, impaired taste, blurred vision, urinary retention, and heart palpitations.
A recent study reported a potential link between the development of dementia and/or brain atrophy and long-term, high-level anticholinergic use by older people, therefore those aged 65+ are generally not prescribed these medications.
The wide-ranging side effects and potential long-term risks of continued use of these medications make them a less-common prescribed treatment, and are often prescribed only when all other treatment routes have failed. As stated by hyperhidrosis expert Dr. Benohanian, MD unfortunately, the anti-cholinergic effects generated by these medications are worse than the sweating itself:
- High effectiveness.
- Can treat the whole body at once.
- Easy to use (just remember to take it everyday, or as prescribed).
- Expensive and recurring prescription costs.
- Moderate to severe side-effects (immediate and potentially long-term).
- Cannot target or “spot treat” specific areas of the body.
- Must be taken every day.
Tap Water Iontophoresis
Tap water iontophoresis is often considered a first or second-line treatment option for hyperhidrosis, and is generally prescribed and/or recommended for those who traditional antiperspirants don’t work. It is a non-invasive, drug-free, and needle-free treatment that is generally done at home with a small, portable medical device.
How does iontophoresis for hyperhidrosis work?
Tap water iontophoresis for the treatment of palmar (hand) and plantar (foot) hyperhidrosis can be traced back at least as far back as the 1940s. Since its introduction, it has undergone significant technological advancements and developments and now with the help of devices like Dermadry, treatment can be done at home.
This technology works by directing a mild current through the skin, neutralizing the connection between the nerves and sweat glands. Iontophoresis treatment is done with a medical device, which is plugged into a power source that produces an electrical current that travels via tap water (the conductor), reaching the conductive electrodes that are submerged in water and touching the skin. A protective barrier, such as a towel or sponge is used to make treatment more comfortable by protecting the skin from coming into direct contact with the electrodes. In nearly all cases, this dramatically reduces excessive sweating.
Iontophoresis is a non-invasive (doesn’t penetrate the skin), drug-free, and needle-free way to treat hyperhidrosis. Many doctors recommend and prescribe iontophoresis to those who have no luck with traditional antiperspirants. It is a safe and effective method to treat hyperhidrosis with limited minor side effects, such as temporary skin irritation and reddening.
Iontophoresis treatment is separated in two phases: the initial phase and the maintenance phase. Depending on the severity of hyperhidrosis of the user (mild, moderate, or severe) an initial treatment phase is followed, which generally lasts from 1-4 weeks (3-5 treatments a week), until the patient achieves their desired level of dryness. A maintenance phase must then be followed to upkeep dryness, which can be several times a week to just once every few weeks/months, depending on the user’s level of hyperhidrosis and their skin.
- High effectiveness.
- Treatment done at home.
- One-time buy.
- Easy to use.
- Treatment schedule must be maintained.
- Can cause mild skin irritation.
Microwave thermolysis (also known commercially as Miradry) is a way to permanently treat excessive sweating of the underarms only. It uses thermal energy to permanently eliminate sweat glands in the underarm region.
How does microwave thermolysis for hyperhidrosis work?
The procedure is done with a non-invasive handheld device that delivers electromagnetic energy beneath the underarm skin resulting in thermolysis (decomposition by heat) of the sweat glands. Microwaves target the layer where the sweat glands are, therefore not burning the surface of the skin. It can also help eliminate body odour emanating from the underarm region (bromhidrosis) and underarm hair permanently.
It is done in a licensed practitioner’s office, who numbs the skin prior to the treatment with local anesthesia. Due to it having to be done in a practitioner’s office, the treatment has limited availability. available in select cities, so you may have to travel in order to get the procedure. The procedure itself is quite costly, generally costing US$3,000 per treatment session. Some require one treatment session, while many require a second treatment session for satisfactory dryness. In some cases, a third treatment may be necessary, but this must be discussed with a health professional. The most common side effects are underarm swelling, numbness, redness and soreness.
- High effectiveness.
- Permanent treatment
- Can also eliminate underarm odour and hair.
- Costly (>$3,000 per treatment on average).
- May need more than one treatment session to see results.
- Only for underarms.
- Limited availability (select cities in approx. 50 countries), may require travel and associated expenses.
- Must be done in a licensed practitioner’s office.
Methenamine is a chemical used topically on the skin to treat excessive sweating, generally of the hands. This is commonly used by and marketed to rock climbers, as this cream builds a strong, thick callus on the skin. It makes the skin dry and rough, which is perfect for climbing. Some who suffer from hyperhidrosis have turned to creams with the active ingredient methenamine to help keep their hands dry. The cream comes under many brand names, the most popular being Antihydral.
What is the active ingredient in methenamine?
Methenamine is a polycyclic organic compound which release ammonia and formaldehyde at acid pH. So when it is applied topically on your skin, methenamine reacts by producing formaldehyde and ammonia (skin acting as acid pH).
The concentration of the formaldehyde in this concentration is low (5%), however there have not been any studies on the safety of these products and any potential long-term effects. Research on methenamine for hyperhidrosis is scarce, and while there are no studies suggesting its use to be linked to any serious health conditions, there are no studies disproving the link either.
How does methenamine for hyperhidrosis work?
Methenamine decomposes into ammonia and formaldehyde on the skin, which dries it out and builds a thick callus. Formaldehyde is a known carcinogen that works as a potent antiperspirant. Pure formaldehyde is never to be used directly on the skin due and is not recommended for constant application and exposure.
- Easy to use.
- Dryness can last several days.
- Limited availability (must be imported into most countries).
- Long-term side effects unknown.
- Leaves formaldehyde on the skin, which is a known carcinogen.
- To treat hands only (as it creates very rough skin).
Surgeries for Hyperhidrosis
Endoscopic thoracic sympathectomy (ETS) is a highly risky procedure that is only reserved for the most severe cases of palmar (hand) hyperhidrosis. Similarly, endoscopic lumbar sympathectomy (ELS) is used to treat the most severe cases of plantar (foot) hyperhidrosis, however it is not widely studied and therefore, we will focus on ETS.
While ETS and ELS are highly advised against due to the inherent risks they pose and the unwanted side-effects, other less risky surgeries exist for underarm sweating. These are "local surgeries", so generally the patient does not have to go under full anesthesia. The surgeries include excision, liposuction, and curettage.
How does ETS surgery for hyperhidrosis work?
During ETS surgery, a surgeon will attempt to interrupt the transmission of nerve signals from the spinal column to the sweat glands to stop the sweating. The patient is under general anesthesia when the procedure is done, as the surgeon must temporarily collapse a lung in order to destroy the nerve paths associated with the overactive sweat glands. It is generally done to treat severe cases of palmar hyperhidrosis, when no other treatment options have worked.
This is a permanent procedure, no successful reversals have ever been done. The procedure is highly risky and generally results in compensatory sweating all over the body, which is often even more excessive than the sweating the patient was experiencing before. While some patients may experience dryness in their hands, they will be sweating excessively everywhere else on their body, which can be even more life-altering than palmar hyperhidrosis.
Some of the most serious side-effects include compensatory sweating, gustatory sweating, Horner’s syndrome, neuritis and neuralgia, brachial plexus Injury, extreme hypotension, heat intolerance, and arrhythmia. Additionally the general risks associated with surgery and undergoing anesthesia must also be considered.
The International Hyperhidrosis Society advises against this surgery, and notes on their website that there are often irreversible side effects caused by endoscopic thoracic sympathectomy (ETS) surgery, and it has even led to death in some cases.
You can read the stories of many who have undergone this procedure and regret it in forums dedicated to raising awareness of the dangers of this surgery. For first-hand experiences, consult ETS Awareness, a project dedicated to raising awareness of the dangers and side-effects of ETS surgery.
- None to note.
- Serious and life-threatening side effects.
- Full-body compensatory sweating as a side-effect in nearly all cases.
- Permanent and irreversible.
- Banned in some countries due to its dangers (including Sweden, where it originated from).
- Limited availability (many doctors refuse to perform this due to the side-effects outweighing the positive).
Treatment for Secondary Hyperhidrosis
If you experience a sudden onset of excessive sweating, or suspect it may be linked to another health issue or medication you are taking, please consult your healthcare provider. Secondary hyperhidrosis is caused by an underlying medical condition and can also be a side-effect of a medication. In this case, the best way to treat that is by identifying and treating the root cause or medication causing the excessive sweating.